What is the best treatment for acne vulgaris?

Best Treatment for Acne Vulgaris

Start with a topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) applied once nightly combined with benzoyl peroxide 2.5-5% once daily as first-line therapy for mild to moderate acne, and add oral doxycycline 100 mg daily for moderate-to-severe inflammatory acne, always with concurrent benzoyl peroxide to prevent antibiotic resistance. 1, 2, 3

Treatment Algorithm Based on Acne Severity

Mild Acne (Primarily Comedonal)

• Apply topical retinoid monotherapy once nightly as the foundation of treatment because retinoids directly target microcomedone formation, normalize follicular keratinization, and are comedolytic 1, 4
• Retinoid options include adapalene 0.1% or 0.3% gel, tretinoin 0.025-0.1% cream/gel, or tazarotene 0.05-0.1% cream/gel/foam 1, 2, 4
• Add benzoyl peroxide 2.5-5% once daily if comedones are moderate or to prevent future inflammatory lesions 2, 4
• Lower concentrations of benzoyl peroxide (2.5%) cause less irritation than higher concentrations with similar efficacy 2, 4

Moderate Acne (Mixed Comedonal and Inflammatory)

• Use fixed-dose combination products containing topical retinoid + benzoyl peroxide as first-line treatment 1, 3
• Add topical antibiotics (clindamycin 1% or erythromycin 3%) for inflammatory lesions, but always combined with benzoyl peroxide—never as monotherapy due to resistance risk 1, 2, 3
• Fixed-combination products (clindamycin 1%/BP 5%, erythromycin 3%/BP 5%) enhance compliance 2, 3
• Alternative: azelaic acid 15-20% gel twice daily, particularly useful for post-inflammatory hyperpigmentation in darker skin types 2, 3

Moderate-to-Severe Inflammatory Acne

• Prescribe triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide 1, 2, 3
• Doxycycline 100 mg once or twice daily is strongly recommended with moderate evidence 1, 2
• Minocycline 100 mg once or twice daily is conditionally recommended with moderate evidence 1, 2
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development 1, 2, 3
• Subantimicrobial doxycycline dosing (20 mg twice daily to 40 mg daily) has shown efficacy for moderate inflammatory acne 3

Severe Nodulocystic or Treatment-Resistant Acne

• Oral isotretinoin is strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne failing standard treatment 1, 2
• Start with 0.5 mg/kg/day and increase to 1.0 mg/kg/day as tolerated, targeting a cumulative dose of 120-150 mg/kg 2
• For moderate treatment-resistant acne, lower doses of 0.25-0.4 mg/kg/day can be used with equal efficacy and fewer side effects 2
• Adjuvant intralesional corticosteroid injections (triamcinolone) can provide temporary benefit for larger inflammatory lesions while starting standard therapy 1, 3

Hormonal Therapy for Female Patients

• Combined oral contraceptives are conditionally recommended for inflammatory acne in females, with moderate certainty evidence showing 62% reduction in inflammatory lesions at 6 months 1, 3, 5
• Spironolactone 25-200 mg daily is useful for females with hormonal acne patterns, antibiotic-intolerant patients, or those preferring to avoid oral antibiotics 1, 2, 3
• Potassium monitoring is not required in healthy patients on spironolactone 2

Maintenance Therapy After Clearance

• Continue topical retinoid once nightly indefinitely to prevent recurrence, as retinoids prevent new microcomedone formation 1, 2, 3, 4
• Add benzoyl peroxide 2.5-5% once daily if needed for more severe baseline disease 2

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide 1, 2, 3, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2, 3
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment including possible isotretinoin 1, 3
• Avoid using topical antibiotics for purely comedonal acne, as they are ineffective against comedones 4

Managing Common Side Effects

• Topical retinoids commonly cause dry skin, peeling, erythema, and photosensitivity 1, 4
• Mitigate irritation by starting every-other-night application, waiting 20-30 minutes after washing before applying, and using concurrent emollients 4, 6
• Apply daily sunscreen to reduce photosensitivity risk 4, 6
• Some tretinoin formulations should be applied in the evening due to photolability and should not be used with benzoyl peroxide 3
• Adapalene is more photostable than tretinoin and can be used with benzoyl peroxide 2

Additional Considerations

• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and does not require G6PD testing 2, 3
• Clascoterone 1% cream (topical antiandrogen) applied twice daily is conditionally recommended but has high cost 1, 2
• Treatment for back acne follows the same severity-based approach as facial acne 3
• Improvement typically occurs by 12 weeks, with continued improvement through 6-12 weeks of therapy 6